Basic Information
| Provider Information | |||||||||
| NPI: | 1053483735 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PREMIER MEDICAL MANAGEMENT OF MISSISSIPPI, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 864 WILSON DR | ||||||||
| Address2: | SUITE C | ||||||||
| City: | RIDGELAND | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391574512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012066100 | ||||||||
| FaxNumber: | 6012066052 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 MARSHALL ST | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392021651 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013522273 | ||||||||
| FaxNumber: | 6013534414 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2006 | ||||||||
| LastUpdateDate: | 09/16/2011 | ||||||||
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| AuthorizedOfficialLastName: | LAY | ||||||||
| AuthorizedOfficialFirstName: | DONNA | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF PATIENT'S ACCOUNTS | ||||||||
| AuthorizedOfficialTelephone: | 6013522273 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0800X | Y | Ambulatory Health Care Facilities | Clinic/Center | Endoscopy |
ID Information
| ID | Type | State | Issuer | Description | 00770341 | 05 | MS | MEDICAID | 490004328 | 01 | MS | RAILROAD MEDICARE | OTHER |